Vietnamese American College Students' Knowledge and Attitudes Toward HIV/AIDS

T

In the United States today, Asian and Pacific Island Americans (APIs) are an ethnic minority whose rates of HIV infection are lower than those of Blacks or Hispanics.[1] This lower incidence may reflect a variety of factors, including behavioral differences in intravenous drug use and sexual behavior and underreporting of HIV infection in Asian Americans.[1-3]

Yet there is cause to be concerned about the future incidence of HIV infection in the Asian American communities. Available information suggests that AIDS cases among Asian Americans are increasing rapidly[4-6] and that the incidence of AIDS is increasing at a higher rate among APIs than among Whites. Between 1992 and 1993, newly reported AIDS cases among APIs increased by 129% (from 335 cases reported in 1992 to 767 in 1993), compared with 117% among Whites (from 22,240 to 48,240).[7] A 1993 expansion of the case definition in the AIDS Surveillance Report resulted in a large increase in reported cases that year, followed by declines in numbers of reported cases each year from 1994 through 1996[7] However, it should be noted that the 561 AIDS cases among APIs during 1996 was higher than the number (335) reported during 1992. Unfortunately, current data on AIDS cases and HIV infection have not been separately collected among Asian ethnic groups in the United States, and AIDS cases in this group may also be underreported or underestimated because of misclassification of race or ethnicity on the medical records that are the source of information on disease rates.

Asian American college students report lower rates of sexual activity relative to other racial and ethnic groups, yet once they become sexually active, their risk-taking behavior patterns are similar to those of young adults in other ethnic groups.[8-11] Furthermore, researchers have found that Asian American college students are no different from their non-Asian counterparts in terms of the prevalence of premarital sexual behavior and increasing acceptance of premarital sexuality.[4, 10, 12, 13] Heterosexual Asian Americans are engaging in high-risk sexual practices, such as sexual intercourse without condoms. To date, few published studies have reported on HIV-related knowledge and attitudes in the Asian American population.

The incidence of AIDS is increasing at a higher rate among male homosexual Asian and Pacific Islanders than among all White males.[7] HIV/AIDS among gay or bisexual APIs has been the subject of little research, which may reflect APIs' lack of a common culture, history, or language. In many Asian cultures, denial and suppression of homosexuality are prevailing attitudes, and speaking of sexuality remains taboo? Acculturation into a society where education about homosexuality exists may be difficult for APIs; learning about HIV and AIDS may therefore be problematic because so few culturally and linguistically appropriate HIV prevention education services can be found in the community.

In this study, I examined the knowledge and attitudes associated with HIV/AIDS and AIDS prevention in a sample of Vietnamese American college students. I hope that the results of this assessment can help health educators develop culturally and linguistically relevant educational materials. I attempt to examine the role of acculturation in explaining the students' knowledge and attitudes toward prevention, defining acculturation conceptually as the process of change that occurs from continuous contact between cultural groups in an atmosphere in which one cultural group is dominant over the other. I viewed acculturation as a multifaceted phenomenon composed of three dimensions language, ethnic identity, and sociocultural preference.

If the level of acculturation is an important influence on knowledge and attitudes toward health issues, in general, then it is reasonable to hypothesize that acculturation is also related to knowledge and attitudes associated with HIV/AIDS and AIDS prevention among Vietnamese American college students. Identifying these possible differences is important because of their potential use in future development of culturally appropriate and sensitive HIV prevention programs targeted toward APIs. The study will provide empirical data specific to Vietnamese American college students and help narrow the information gap that currently impedes efforts to develop appropriate education programs.

METHOD

This project was reviewed and approved by the University of Houston Committee for the Protection of Human Subjects. I chose to study Vietnamese students at the University of Houston because they represent the largest group (13.5%) of Asian Americans at the university. I reviewed names listed in the student directory and identified 30 Vietnamese family names that account for the majority of all ethnic Vietnamese. The final sample consisted of 847 Vietnamese students enrolled during the 1994/1995 academic year; only students who identified themselves as Vietnamese were included in the final sample.

I collected data between July and October 1996, sending students a letter requesting them to complete a questionnaire and return it in an enclosed self-addressed stamped envelope. Sixty-eight letters were returned because of insufficient addresses, and I excluded those students from the study. I recruited and trained three investigators to conduct telephone interviews with the students who did not return the survey. They made a maximum of three attempts to reach students; the telephone interviews were conducted in English and lasted 10 to 15 minutes. Our inability to get correct telephone numbers was the most common reason for nonresponse. The mailing and telephone surveys resulted in 412 completed surveys from the eligible list of 779, a final response rate of 53%. Nine percent of those we reached refused to participate in the survey; 2 people did not respond because of language problems.

We used a modified version of the Suinn-Lew Asian Self-Identity Acculturation Scale[14] to ask participants a series of questions aimed at assessing the degree of their acculturation into US society. The areas covered and ranges of responses (higher scores indicate greater acculturation) included language use and preference (range = 7-21), ethnic identification (range = 2-6), and sociocultural preferences (range = 3-9). As anticipated, we found positive correlations between language and ethnic identity (r =.47, p [is less than].001) and between the length of residence in the US and language use (r =.48, p [is less than].001).

Language use also showed a positive correlation with ethnic identity (r =.53, p [is less than].001). Respondents who had lived in the United States for longer periods were more likely to use English than those who were more recent arrivals. These correlations in the expected direction provided some construct validity for the scale.

The questionnaire was pilot tested for comprehension with members of the target population, then revised. It was designed to assess demographic information, acculturation, and prevalence of HIV-related knowledge and attitudes. I used the SYSTAT statistical analysis system[15] to analyze the data; tests of significance included chi-square for cross tabulations and t tests for continuous variables.

RESULTS

Demographic Characteristics

The respondents were students (205 men and 207 women) aged 17 to 48 years (M = 23 y); approximately 56% were between the ages of 21 and 25 years, and 92.7% had never been married. More than 65% were employed; about 60% of the employed students worked 11 to 30 hours per week. More than half of the students lived in a household with an annual income of more than $30,000; household earnings in 26.2% of the Vietnamese households were less than $20,000.

The average length of residence in the United States was 14.7 years (SD = 5.8 years, range = 2 months to 26 years). Nearly 90% of the students surveyed were born outside the US mainland. Although a majority of respondents were born in Vietnam, more than 60% of the respondents were raised in the United States.

Knowledge and Attitudes About HIV/AIDS Prevention

Participants' knowledge about AIDS and HIV/AIDS prevention was inconsistent (see Table 1 for a summary). For example, only 36.7% responded correctly to the statement, "HIV cannot be cured if it is detected and treated early." Less than half (45.6%) responded correctly to, "You can get HIV from using a public toilet." A majority of respondents, however, had greater levels of knowledge about risk-reduction methods.

Although 90% of the respondents knew that using condoms can lower the risk of getting AIDS, 25% of respondents did not know that using condoms with spermicide during sexual intercourse reduces the chances of becoming HIV infected. The majority (93%) of the respondents knew that abstinence reduces the chance of infection.

Gender was significantly associated with students' knowledge: Women had more knowledge than men. Approximately 40% of the men who responded gave incorrect responses on all of the questions, compared with 24% of the women.

Table 2 presents knowledge scale means and standard deviations, by gender and selected health behaviors. I formed sum scores for the 11 items that were measured by a true-false response set. The resulting scale had a range of 0 to 11. The higher the mean score, the more the respondent knew about prevention of HIV/AIDS. The mean number of correct responses for the portion of the questionnaire concerning knowledge of AIDS was 5.15 (SD =4.01). More than 30% (n = 130) of the respondents gave incorrect responses on all of the knowledge questions. Those who smoked and drank alcohol were less knowledgeable than nonsmokers or nondrinkers, and users of marijuana were less knowledgeable than those who had never used marijuana.

I also found significant differences in knowledge between the sexually active and nonactive respondents. Of the sexually active, 70% reported that they were using some means of contraception. Condom use was the most common method, and about 60% reported always using a condom.

I found no significant differences between knowledge score and acculturation variables. However, it should be noted that the degree of acculturation was significantly related to smoking, alcohol, marijuana use, and active sexual behavior. In general, acculturated students were more likely to smoke, drink, use marijuana, and be sexually active than the less acculturated students, who also were less likely to report ever having had sexual intercourse.

Seventy percent of the respondents stated that their chances of getting HIV were very low. More than half (60%) indicated that they worried about the possibility of getting HIV/AIDS, even if they were careful. Seventy-six percent of the respondents felt comfortable talking about safe sex with friends, and 93.4% believed that sexual partners needed to be open and honest about their previous sexual experiences.

One third of the respondents, however, said that they would find it difficult to ask a sexual partner or potential partner about his or her previous sexual experiences and other partners. About one fifth of respondents felt that talking about safer sex and the use of condoms might scare off a romantic partner. Nearly one fourth of the respondents indicated that they are not receiving enough information about how to protect themselves from becoming infected with HIV; 34% of the survey participants did not know where to go if they wanted an HIV test.

COMMENT

AIDS Awareness

The serious nature of AIDS and HIV infection was somewhat understood by the respondents, and a majority said they feared AIDS. My findings indicated that Vietnamese students in this study were aware of the major modes of HIV transmission, but they had some misconceptions about transmission through casual contact (eg, 31% thought that "Asians are immune to HIV because it is a western epidemic that does not effect Asians").

This finding underscores the importance of offering culturally sensitive HIV/AIDS education that addresses misconceptions. It is particularly important to address the common misinformation among
Vietnamese and other Asian students that Asians do not catch AIDS. Information targeted to all college students may not be enough to inform Vietnamese and other Asian population groups.

The US Department of Health and Human Services has set a goal for the year 2000 of providing HIV/AIDS education for students and staff in at least 90% of colleges and universities.[16] However, the knowledge level of the Vietnamese American students who participated in this study fell far short of that goal. The low level of the Vietnamese students' knowledge reflects a lack of HIV education targeted toward this population.

Interpersonal Communication and Acculturation

Authors of previous studies[4, 8, 17] reported that Asian American students report significantly less AIDS-related interpersonal communication than their North American counterparts. This is consistent with our finding that Vietnamese American students were also less likely to discuss HIV with sexual partners. In another study, Horan and associates[8] found that Asian young adults were less likely to discuss sexuality openly and had less ability to communicate with others about HIV infection and prevention than White, Hispanic, and Black students. This general finding confirms the lack of sexual communication between partners among Vietnamese students. Although sexuality is viewed as a normal part of life, young Asians are less likely than other ethnic groups to discuss sexuality.

Traditionally, Asians are socially more conservative than Europeans and North Americans in their expressions of sexuality.[19] A culturally appropriate HIV/AIDS program must help students learn to communicate effectively in sexual situations, and future research must investigate the impact of culture in interpersonal communication. As expected, the more acculturated Vietnamese students in this study had higher rates of sexual activity, an indication of the strong influence of Americans sexual customs. Previous studies[18, 19] showed that acculturation was positively related to having experienced premarital intercourse and negatively related to the age at first coital experience. Asian Americans who came to the United States a long time ago are more likely to adopt Western society's behavior and attitudes, in contrast to Asians who arrived more recently. One could expect that the influence of American sexual values would vary as a function of the amount of exposure to the new culture. Although Vietnamese students in this study reported lower rates of sexual activity, relative to other racial or ethnic groups, one can speculate that once they become sexually active, their risk-taking behavior patterns may be similar to those of sexually active young adults in other ethnic groups.

Findings from previous studies[1, 8, 10] have suggested that sexually active young adults, especially college students, are increasingly knowledgeable about AIDS and HIV transmission. However, in this study, sexually active students were less knowledgeable than those who were not sexually active. Those students who engaged in risky behaviors (eg, smoking, drinking alcohol, using marijuana) seemed to be less knowledgeable. The study findings also showed that the students' level of acculturation was related to risk-taking behavior. This finding suggests that acculturated students are more likely to be at risk of contracting HIV than students who are less acculturated and underscores the need for more education about AIDS for Vietnamese students, and especially for those who are sexually active.

Limitations

This is a preliminary study that is limited in several ways. The students' attitudes toward homosexuality and male-male transmission were not surveyed because using terms such as gay and lesbian might discourage participation. Much stigma is attached to the role of homosexuality, and many gay APIs are still "in the closet," fearing that if they are labeled as homosexual, their families and the community may reject them. This emphasizes the need for HIV prevention interventions that provide complete anonymity and confidentiality and that students perceive that their identity will be protected.

Future HIV prevention programs for the API community must address the important sociocultural issues of stigmatization and confidentiality. Self-administered surveys often yield lower response rates and more missing data than in-person interviews, although no significant differences are evident in results between the two kinds of surveys. However, it is possible that students would be less willing to respond to our questionnaire during telephone interviews than on written surveys dealing with their sexual experiences.

Because it is usually not culturally acceptable for Asians to discuss sex openly or admit to having sexual encounters, it is also possible that respondents were less likely to have reported their behavior accurately. For instance, people often respond as they think the interviewer wants them to, answer in a way that makes them appear more competent and more successful, deliberately provide inaccurate data to hide risky health behavior, have incomplete or inaccurate memories of events, or respond to a hypothetical question in a way that is unlikely to predict real behavior accurately.

Another limitation is that we have no data on those students who did not respond. One can assume that students who were less knowledgeable about HIV/AIDS and those who engage in risky behaviors would not participate in this study. The sampling frame was limited and based on student listings. We studied only Vietnamese students on one cam pus; therefore, our data cannot be generalized to the population of Vietnamese or other API students as a whole.

Cultural Perceptions

Traditional methods of evaluating outreach projects for APIs should be reexamined. Paper and pencil approaches to assessment, for example, may carry connotations of testing (eg, cultural attitudes toward being evaluated by a perceived teacher), social desirability, maintaining "face," and potential shame associated with disclosure of intimate behavior to a stranger.

Cultural perceptions with respect to sexuality, sexual practices, sexual orientation, and illness (HIV-related conditions) must be taken into account. Those who develop prevention programs should be particularly cautious in using such terms as HIV/AIDS, gay, lesbian, and sex in outreach programs because the terms are likely to discourage participation.

To increase participation of Vietnamese and other Asian students and to be effective, health educators should work with Asian student organizations on campus and include representatives from these student organizations during the program-planning phase. Because Asians do not discuss sexuality openly in public, HIV/AIDS education might be incorporated into other health promotion programs tie, diet and exercise), where Vietnamese or other API students will feel less threatened

Despite the large number of Asians now living in the United States, only a few studies have examined sexual behaviors among Asian Americans. The effects of acculturation on attitudes toward sexuality and on sexual and other risky behaviors need to be examined in future studies. Attitudes toward homosexuality may change with acculturation, but current attitudes toward homosexuality need to be explored in future studies.

For rates of HIV infection to remain relatively low among Asians, health educators need to initiate culturally and linguistically appropriate HIV/AIDS prevention programs. Most HIV/AIDS programs are not now addressing the needs of Vietnamese and other Asian students, leaving many of these young adults uninformed.

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[15.] Steinberg D, Colla P. Evanston: SYSTAT; 1991.

[16.] Health), People 2000. US Department of Health and Human Services, Public Health Service. DHHS publication PHS 91-50212; 1990

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